DEP/DUA/1/28/17 (Normalised version)

James Grinlay

(1781-1782)

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James Grinlay.

In symptoms described in history of this patients case nothing uncommon.

But in progression which affection has had something which to me seems singular.

When came under our care principal affection consisted in pains in different parts

Chiefly however affecting dorsal & [frequently] lumbar vertebrae.

These had little hesitation in considering as being of Rheumatic kind.

Was indeed it must be allowed with some peculiarities.

Did not affect those parts in which Rheumatism commonly seated.

For had as it were alternation between back & breast.

And this alternation too pretty much at stated periods.

To latter in general confined through course of day, to former during night.

Such a course though may sometimes take place cannot at least be represented as frequent in Rheumatism.

And still less frequent to find pains of Rheumatic kind relieved from discharge of wind.

This however told in history, was very much case with present patient.

From these circumstances however, [although] rather uncommon saw nothing which could lead us to conclude against Rheumatism.

And consider them as at least [reconcilable] to that supposition.

Latter circumstance in particular was disposed to explain from situation of affection.

And ascribed it to removal of distension from pained parts.

A necessary consequence of wind being discharged from alimentary canal.

While former, alternating between back & breast, considered merely as being nothing more than particular modification of those sudden changes of situation to which Rheumatic pains subjected.

For to be observed that in Rheumatism much more frequently the case to find pain shifting situation, than for long time static.

And if in some particulars here rather singular, in many others most ordinary appearance.

This particularly the case with respect to parts formerly affected.

First attack of pain on shoulder a very common seat of Rheumatism.

After affected lumbar vertebrae.

These however still more frequently observed.

In so much that as seated there has given name to a disease very generally considered as of Rheumatic kind viz. Lumbago.

In these situations could be little doubt that of Rheumatic kind.

And although situation changed when came under our care, yet could have no hesitation in considering it as of same kind.

This Rheumatic affection when applied for assistance at the Dispensary the most considerable & urgent part of his disease.

[very common consequence of being sedentary]

But besides this then also complained of sense of numbness in legs & thighs

With this symptom however had at that time been affected only for space of few days.

And if any diminishment of power of [motion] was but very inconsiderable.

[Seemed] indeed to himself that [besides] numbness legs rather colder than natural.

But as far as judgement could be formed by feeling of others, still [retained] natural heat.

At that time therefore was I own disposed to consider this numbness as of but little consequence.

And looked upon it as being merely effect of want of usual exercise.

From which prevented by pains.

Well known that with those habitual to exercise

In this manner probably takes place from want of due circulation.

Imagine therefore that here no [illegible] would be necessary for removal.

But that of itself would soon cease when pains mitigated & exercise [resumed]

With regard to pains also, saw nothing to give any alarm.

Had indeed continued for some length of time, & could not be represented as slight.

But were at least, so far tolerable that neither confined him to bed, nor house.

And although had subsisted for several weeks, yet during that time, had not been static to any particular place.

But had affected by turns several different parts.

And during that period had not resisted any medicine calculated for removal.

For when came under care, were told that had used no medicines.

Hence then hoped in short time to obtain alleviation if not complete removal of affection

In this expectation however soon found that was mistaken.

And indeed complaint in one particular, took very different turn from what expected.

For although pains much diminished yet insensibility of lower extremities very much increased.

And with this also, loss of power of motion.

Now therefore conclude that paralytic affection by no means of that slight nature, which had supposed.

And if not most uneasy, had every reason to believe, would be most obstinate part of disease.

Still however inclined to look upon it, as consequence of Rheumatic affection.

But not from any diseased state which rheumatism had induced in those parts, in which affection seated.

As pain often severe in dorsal or lumbar vertebrae was inclined to suspect that spinal marrow affected.

And that paralysis here neither from affection of nerves at origin nor external, but in course.

But whatever cause in consequence of paralytic affection patient became incapable of attending us at Dispensary

And may set out with observation that consider Rheumatic affection as claiming first and & principle attention.

Most practitioners have divided affection into two states Acute & Chronic.

For this division unquestionably a foundation in nature.

Yet inclined to think that rather too general.

And as now under care of another Physician, being a patient in the infirmary reckon it improper to say anything farther either with respect to probable event of disease, or practice which may be most successfully employed.

Shall confine farther observations on case then to remarks on those modes of cure which employed while under our care.

O

In treatment of Rheumatism in general intention of cure very much varied.

For these, must be accommodated to state of [disease]

Shall afterwards have occasion to show in practical lecture that in four different states each requires particular treatment.

Those viz of inflammation of irritability of atonia & of Paralysis.

Into particular objectives to be aimed at in each of these would be foreign to present business to enter.

Sufficient to observe that viewed disease of present patient as being in 2^d of these states, that viz of Irritability.

In that state should be objective not so much to combat active inflammation [already] existing, as to remove disposition to it.

And while endeavour to prevent action of causes exciting pain, to attempt to obviate influence when do act.

These ends may be accomplished on different footings

But chiefly by counteracting effects of morbid sensibility.

On these general principles will readily [understand] intentions which had in view in practices here employed.

First prescription to patient was a topical application

That viz of Anodyne Balsam.

This article has long had place in pharmacopoeia¹ of Edinburgh College².

In different editions of work indeed since beginning of [present] [certain] formulas somewhat varied.

Yet in all these the active ingredients Camphor & Opium.

These for giving necessary form diffused in spirit of wine

Addition of soap principally to promote & support union.

While Saffron oil of Rosemary etc which have often been added either to give smell or colour.

In two constituents then which are basis of this medicine, have articles operating very powerfully on nerves.

And perhaps may add that no article yet a place in pharmacopoeia which have more powerful influence as counteracting morbid sensibility.

Accordingly few more effective as immediately allaying excessive pain.

And that both as acting on system in general, & when immediately applied to pained part

Accordingly under present formula that viz of anodyne Balsam, often used to great advantage.

From this then hoped, that in present instance, effect of morbid sensibility would be counteracted & pain mitigated.

But besides Anodyne Balsam, had at same time also recourse to another prescription.

Powder viz constituting of Cream of Tartar united to Gum Guaiacum

The latter of these articles in different forms has long been much celebrated in Rheumatism cases.

And in my opinion principally useful when Rheumatism in that state here [supp]

In my own practice have frequently employed it with best effects.

Form however in which have given it has almost always been that of Volatile Elixir.

And there must be allowed some doubt whether efficacy does not as much depend on volatile alkaline in [menstruum], as on Guaiacum

Here therefore wished to try it in formula where if had good effects had no room to doubt of article to which to be attributed.

But besides this had another inducement also for employing it in substance.

That was good effect which had lately seen derived from it exhibited in this manner in another case.

Some indeed who are advocates for Guaiacum as given in solution, yet contend that nothing to be expected from it in substance.

For that in this state will not be dissolved in alimentary canal.

But although admit that in its nature more a resinous than [gummy] [substance] can by no means adopt this opinion.

Here however no doubt that solution much aided by division of parts

And was with view of giving such, that here combined with considerable proportion of Cream of Tartar.

From which also expected that immediate action of resinous quality as irritating stomach would be diminished

At same time hoped that would have effect of promoting discharge by surface

And that by combination of stimulant & diaphoretic powers would bring about removal of disposition to increased action in vessels.

These then expectations entertained from practices here directed.

And in obvious operation, of latter medicine at least were not disappointed.

For had effect of producing gentle diaphoresis

And to this was in part at least inclined to attribute mitigation of pain which here took place.

Yet must own was principally inclined to attribute it to anodyne balsam.

To use of which recourse regularly had twice a day.

With mitigation of pain however to be observed, that numbness & insensibility of parts still continued.

And although belly formerly natural yet now rather bound.

An effect the opposite of that which had reason to expect from use of ℥ii of Cream Tartar in day.

This however disposed to attribute to discharge by skin being augmented.

While still hoped that with removal of pains insensibility might also [illegible] off

In expectation therefore of farther [mitigation] still directed continuation of same practice.

Only adding to each powder an additional ℥ of Cream of Tartar.

By this hoped belly would be effectively moved

And in this expectation were not at least altogether disappointed.

For had at first effect of gently moving belly.

After few days continuation however influence in this way diminished.

In so much that at succeeding report again rather bound.

Still however pains continued much easier.

But contrary to what expected would have been consequence of such mitigation numbness & insensibility increased.

And now also attended with circumstances from which reason to be more alarmed

For was by no means with ordinary progress from irritated to paralytic state of Rheumatism.

In that case transition in general from severe pain, to great weakness.

And is only after some continuation of this atonia, that terminates in paralysis.

There also paralytic affection for [some] time at least, in general confined to seat of former pain.

But here not limited to that

For now affected to very considerable degree whole of inferior extremities.

And that too without any preceding pain or weakness either in muscles or joints of these.

Now therefore viewed this in light of more serious paralytic affection.

And imagine that supervening costiveness or rather difficulty of moving belly by proper purgative might proceed from same affection being in some degree extended to alimentary canal.

In this state, as now very little affected with pains thought continuation of Guaiacum unnecessary.

And with Balsam to be topical [application] conjoined a proportion of vitriol Aether.

This unquestionably one of most powerful & penetrating stimulants, which Materia Medica yet affords us.

And if nerves not altogether incapable of [illegible] impression, effects of action on extremities must be communicated to origin.

In this way then expect that might have good effect as restoring proper sensibility.

But with this external application, although Guaiacum omitted, became still more necessary than formerly to move belly.

Still therefore directed continuation of Cream of Tartar.

And as quantity before taken insufficient augmented dose to ℥VI indies.

To this added small proportion of Pulveris Zinzeb.

From which as acting upon stomach as well as other warm aromatic vegetables powerful stimulation given to whole Nervous System

In this way then thought that might here be of some service

But at same time principally employed with view of acting as corrigent to Cream of Tartar.

And what chiefly expected from this medicine was the keeping belly open.

This end however it did not answer

For although took daily what would have operated as brisk cathartic to most [patients], yet had but once stool during course of week.

With this augmentation of obstipation, paralytic affection of limbs, also increased.

Now therefore still more than before was confirmed in opinion of being connected.

And of looking upon affection as now to be treated in light of formal Paralysis

In this state of that disease many different modes of cure of which trial might have been made.

Had patient been able to attend at the Dispensary should probably have had recourse to Electricity.

To this distance from thence as well as inability to walk [uncertain] objections.

Thought therefore as more convenient practice at least of trial of Camphor.

From Camphor in some late cases of Paralysis have I think derived very considerable advantage.

And that more from continual use, for some length of time, than from employment to considerable extent at once.

To reap advantage however requisite that should be given in substance & not in very trifling doses.

Ordered therefore in pills, to extent of about 12 grains in day.

And was intention, if found good effect from it, to increase quantity as persisted in use.

But with this also necessary to conjoin some medicine for moving belly.

And as Cream of Tartar unequal to that affect, had recourse to Pill ex Colocyinth cum Aloe.

Which where there is not very great degree of Torpor in alimentary canal will in general be effective in producing motion of belly

And that too when given to extent of about four or five grains

Here however that might secure operation directed to quantity of grain X.

And even from this had no more than single stool a day.

While at same time from Camphor no alleviation of affection of legs.

On contrary both numbness & insensitivity augmented, & as well as loss of voluntary motion

In so much that now unable either to stand or walk.

In this situation, became unfit patient for our Dispensary practice [where] personal attendance on part of sick themselves is required.

And now a patient in the Infirmary³ where his case may again be subject both of practice & of lecture.

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Explanatory notes:

1) An official publication containing a list of medicinal drugs with their effects and directions for their use. The Royal College of Physicians of Edinburgh's Pharmacopoeia was first published in 1699.

2) The Royal College of Physicians of Edinburgh, established in 1681.

3) The Royal Infirmary of Edinburgh, established in 1729.